Panic Disorder

Panic-like symptoms can be the presenting feature of cardiac arrhythmias, hyperthyroidism, pheochromocytoma, pulmonary embolism, hypoglycemia, and substance intoxication or withdrawal. First presentations, late-onset cases, atypical symptom patterns, or presentations with abnormal vitals warrant medical evaluation before a psychiatric diagnosis. Common initial tests to consider, especially for first or atypical presentations: ECG, and TSH when clinical features suggest thyroid disease or anxiety is new and unexplained.

Caffeine, stimulants, cannabis, and withdrawal states (alcohol, benzodiazepines) can produce or exacerbate panic symptoms. Always screen. Caffeine is the most commonly overlooked contributor — high intake can independently maintain the panic cycle.

Progressive restriction of activities and locations is a signal that agoraphobia may be developing. Early intervention with exposure-based approaches can prevent the avoidance pattern from becoming entrenched. By the time a patient is housebound, treatment is significantly more difficult.

Repeated emergency department visits, frequent requests for cardiac testing, and constant reassurance-seeking from providers maintain the panic cycle by reinforcing the belief that symptoms represent a medical emergency. This pattern should be addressed directly — with empathy, not dismissal — as part of the treatment plan.

Patients started on benzodiazepines for panic often have difficulty discontinuing. Withdrawal symptoms can mimic and trigger panic attacks, creating a cycle that reinforces continued use. When benzodiazepines are used, plan the taper from the start. This is both a clinical issue and a commonly tested board concept.